Lessons Learned

in the Acute
Inpatient
Environment
(and the Research)
by Dame Robinson
Wearing Many Hats • The furniture mover—moving furniture, equipment
• The cheerleader—motivating, encouraging
• The teacher—consistently educating patients on the
value of early movement, breathing, home exercises and
self-care
• The caregiver—helping with ADLs, fostering goals, and
caring for needs
• The team player—working with doctors, nursing, SLP, OT,
D/C planning
• The mother—giving firm and direct commands
• The physical therapist—using skill in making decisions to
facilitate discharge and placement, to foster optimal
recovery, and to reduce readmissions

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Pivoting on a Dime:
Clinical Reasoning
• Clinical Reasoning is ongoing with each
patient
• Being able to pivot on a dime depending
on patient presentation
• Consistently navigating the unexpected
challenges
• Changes in patient medical status, vitals,
mobility, and mental status

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Scanning the Room
• Initially, moving furniture and preparing the room to
make space for ambulation
• Preparing all necessary equipment (O2, assistive
device, telemetry box, gait belt, gowns, socks, w/c,
etc.)

• Being mindful of all lines

• Taking vitals before, during and after
• Having a plan if patient is not able to ambulate as
expected (marching in place, lateral side stepping
with bed behind, steps forward/backward,
ambulating with chair or wheelchair behind)

• Leaving the environment the way you found it

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Ascending/Descending Stairs
• Up with the good, down with the bad
• Backwards—using a 2WW and having an
assistant to stabilize the walker
• Sideways—if the post-operative joint
replacement is on the same side as the
railing going up
• Forward—with cane or walker
• Bilateral rails

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Body Mechanics and Helping Others
• Encouraging patients to move, but not leaving a two-
person max lift for other hospital staff at the end of
the shift

• Preparing your body to move the patient—abdominal

draw in, bending the knees

• Preparing the environment to keep your body safe—

raise the bed, use a chair

• Making the time to foster exercise to maintain

strength and personal fitness

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The Impact of Early Mobility
• In a prospective cohort study by Sui et al., the
Research supports early mobility in patients! authors explored early mobility in patients who
were status post hip fracture surgery2
• Kalisch et al. examined early mobility in patients in
acute care setting1 • The authors found:
• Immobility correlated to mortality2
• From 36 reviewed studies: early mobility led to
positive outcomes in physical, social, and emotional • Patients who were mobilized had greater
realms1 independence, autonomy and recovery2
• In an article by Gabele et al. the authors
• Total joint arthroplasty: early mobilization= decreased
reported the following benefits of early
pain, lower cases of DVT and pneumonia1
mobility:3
• Pt mobilized sooner had decreased delirium, • Decreased length of stay at hospital
depression and anxiety1
• Less pressure injuries
• Increased quality of life for patients mobilized • Less decline in functional mobility3
compared to patients who remained immobilized for
hospital stay1

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The Barriers to Early Mobility
In a qualitative study by Pavon et al., the authors
• Lack of time4
found barriers to mobility included interpersonal,
intrapersonal, organizational and environmental4 • Lack of clarification of various health
professional’s roles in patient mobility4
Specific barriers identified in the study:
• Fear of potential falls of patients in the
• A reluctance to move patients before they were
hospital setting4
seen by a physical therapist4
Some suggested solutions in the study:
• Lack of access to tools, assistive devices and
technology to assist in mobilizing patients4 • Programs to train hospital staff (such as
nurses and nurse’s aides) in mobilizing
• The philosophy of the organization that did not patient4
place emphasis on early mobilization of
• Implementing logs of mobilization of
patients4
patients in the hospital (esp. patients not
on physical therapy caseload)4

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 Post Intensive Care Syndrome (PICS)
• Post-Intensive Care Syndrome is a myriad of physical,
cognitive and social issues that emerge after a patient
has been in the intensive care unit for a period of
time6-9
• Physical—deconditioning, ICU acquired weakness
(ICU-AW), decreased functional mobility and ADLs
• Mental—depression, anxiety, post-traumatic stress
disorder (PTSD)
• Social—difficulty re-acclimating work, family and
other social roles
• Cognitive—difficulty with memory, attention, and
coping
• “Symptoms of PICS may appear as early as 24hr after
admission to an ICU and may persist for 5-15 years
after discharge.” 6, p.2
• Suggestions to mitigate PICS:6-9
• Early mobilization in ICU
• Strength training
• Electrical stimulation (NMES)
• Inspiratory muscle training
• ICU diaries
• Reducing environmental stressors (noise, light)
• Fostering multidisciplinary approach to care
The authors suggested prevention of PICS through the
“ABCDEFGH bundle” 9
• Airway Management, Breathing Trials,
Coordination of Care and Communication,
Delirium Assessment, Early mobility, Family and
follow-up referrals, Good Communication and
Handout Materials9
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The Activity Measure for Post-Acute Care (AMPAC)—6
Clicks
6 questions on amount of assistance or level of • However, a qualitative study by Dewhist et al.,
difficulty in explores the insights of therapists on the AMPAC
• bed mobility functional measure:
• sit to stand • They indicated that the tool had utility for administrative or
research purposes. 12
• supine to sit
• Concern that it was too general to substitute for
• transfers,
professional expertise in plan of care and clinical
• ambulation reasoning 12
• stairs9 • Cannot be the sole measure for discharge planning12
In a study by Jette et al. interrater reliability intraclass • Question of accuracy and usefulness of measure12
correlation coefficients were .85 for mobility and .78 for • Did not completely capture a patient’s full functional
activities of daily living with a 95% confidence10 mobility12

In a study by Jette et al, validity was .96 for basic mobility

and .91 for daily activity11

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Active Listening: Paying attention to the patient and the
people in the room

• Clarifying

• Repeat back method to make sure all

mobility information is accurate to
guide evaluation and treatment

• Having collaborative discharge

conversations

• Asking patient how they feel, what

they need and how you can help

• Finding ways to encourage patient so

they take ownership of their healing
journey

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Seeing the Forest Through the Trees: Discharge Planning
• This is always at the forefront of your mind in the
acute inpatient setting
• Consistently evaluating
• Making the best choice for the patient’s safety and
well-being
• Ongoing as it may change day to day
• Not getting caught up in a patient’s expressions of
pain to be able to see as much mobility to get the best
evaluation and make an accurate decision on
discharge
• Writing thorough assessment in documentation to
support discharge recommendations

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Each Patient is Unique
• Patients teach us many things and can enrich our
lives
• Even in a short stay in inpatient setting there is time to
build rapport and make impact on these individuals'
lives
• Take the time to listen and learn
• Explore and recognize biases
• Treating the whole person—considering the
Biopsychosocial factors that influence care
• Biological
• Psychological
• Social

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References
1. Kalisch BJ, Lee S, Dabney BW. Outcomes of inpatient mobilization: a literature review. J Clin Nurs. 2014;23(11-12):1486-1501. doi:10.1111/jocn.12315

2. Siu AL, Penrod JD, Boockvar KS, Koval K, Strauss E, Morrison RS. Early ambulation after hip fracture: effects on function and mortality. Arch Intern Med. 2006;166(7):766-771. doi:10.1001/archinte.166.7.766

3. Gabele D, Mendez S, Giuliano KK. Early and progressive mobility in a community hospital: A new interdisciplinary safe patient handling and mobility model. Nurs Manage. 2023;54(3):22-27.
doi:10.1097/01.NUMA.0000919068.76409.b2

4. Pavon JM, Fish LJ, Colón-Emeric CS, et al. Towards "mobility is medicine": Socioecological factors and hospital mobility in older adults. J Am Geriatr Soc. 2021;69(7):1846-1855. doi:10.1111/jgs.17109

5. Renner C, Jeitziner MM, Albert M, et al. Guideline on multimodal rehabilitation for patients with post-intensive care syndrome. Crit Care. 2023;27(1):301. Published 2023 Jul 31. doi:10.1186/s13054-023-04569-5

6. Hiser SL, Fatima A, Ali M, Needham DM. Post-intensive care syndrome (PICS): recent updates. J Intensive Care. 2023;11(1):23. Published 2023 May 23. doi:10.1186/s40560-023-00670-7

7. Yuan C, Timmins F, Thompson DR. Post-intensive care syndrome: A concept analysis. Int J Nurs Stud. 2021;114:103814. doi:10.1016/j.ijnurstu.2020.103814

8. Inoue S, Hatakeyama J, Kondo Y, et al. Post-intensive care syndrome: its pathophysiology, prevention, and future directions. Acute Med Surg. 2019;6(3):233-246. Published 2019 Apr 25. doi:10.1002/ams2.415

9. “Activity Measure for Post-Acute Care (AM-PAC)—“6 Clicks” Inpatient Short Forms” American Physical Therapy Association website. https://www.apta.org/patient-care/evidence-based-practice-resources/test-
measures/activity-measure-for-post-acute-care-am-pac--6-clicks-inpatient-short-forms. Accessed March 9, 2024.

10. Jette DU, Stilphen M, Ranganathan VK, Passek S, Frost FS, Jette AM. Interrater Reliability of AM-PAC "6-Clicks" Basic Mobility and Daily Activity Short Forms. Phys Ther. 2015;95(5):758-766.
doi:10.2522/ptj.20140174

11. .Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. Validity of the AM-PAC "6-Clicks" inpatient daily activity and basic mobility short forms. Phys Ther. 2014;94(3):379-391.
doi:10.2522/ptj.20130199

12. Dewhirst RC, Ellis DP, Mandara EA, Jette DU. Therapists' Perceptions of Application and Implementation of AM-PAC "6-Clicks" Functional Measures in Acute Care: Qualitative Study. Phys Ther. 2016;96(7):1085-
1092. doi:10.2522/ptj.20150009

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